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<title>
EHS Incident Report
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* Marked fields are mandatory.
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<div style="padding-top: 10px"></div>
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<div style="padding-top: 10px"></div>
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<form action="incident_report.php" method="post" name="incident" id="incident">
<div>
  <table width="700" border="0" cellspacing="0" cellpadding="5" id="main">
        <tr>
            <td style="font-size: small; text-decoration: underline;">1. EVENT TYPE :</td>
            <td></td>
        </tr>
        <tr>
            <td>* Type of event :</td>
            <td>
                <select name="event_type_id" id="event_type_id" tabindex="1">
                <option value="" ></option>
                <option value="1" >Injury</option>
                <option value="2" >Incident (no injury)</option>
                <option value="3" >Hazard</option>
                <option value="4" >Illness</option>
                </select>
            </td>
        </tr>
        <tr>
            <td>* Date of event (mm/dd/yyyy) :</td>
            <td>
            <select name="event_month" id="event_month" tabindex="2">
            <option value="12" >December</option>
            <option value="1"  >January</option>
	        <option value="2"  >February</option>
            <option value="3"  >March</option>
	        <option value="4"  >April</option>
            <option value="5"  >May</option>
	        <option value="6"  >June</option>
	        <option value="7"  >July</option>
	        <option value="8"  >August</option>
	        <option value="9"  >September</option>
	        <option value="10" >October</option>
	        <option value="11" >November</option>
	        <option value="12" >December</option>
            </select>
            <select name="event_day" id="event_day" tabindex="3">
            <option value="15" >15</option>
            <option value="1">1</option>\n<option value="2">2</option>\n<option value="3">3</option>\n<option value="4">4</option>\n<option value="5">5</option>\n<option value="6">6</option>\n<option value="7">7</option>\n<option value="8">8</option>\n<option value="9">9</option>\n<option value="10">10</option>\n<option value="11">11</option>\n<option value="12">12</option>\n<option value="13">13</option>\n<option value="14">14</option>\n<option value="15">15</option>\n<option value="16">16</option>\n<option value="17">17</option>\n<option value="18">18</option>\n<option value="19">19</option>\n<option value="20">20</option>\n<option value="21">21</option>\n<option value="22">22</option>\n<option value="23">23</option>\n<option value="24">24</option>\n<option value="25">25</option>\n<option value="26">26</option>\n<option value="27">27</option>\n<option value="28">28</option>\n<option value="29">29</option>\n<option value="30">30</option>\n<option value="31">31</option>\n            </select>
            <select name="event_year" id="event_year" tabindex="4">
            <option value="2011" >2011</option>
            <option value='2010' >2010</option>
            <option value='2011' >2011</option>
            <option value='2012' >2012</option>
            <option value='2013' >2013</option>
            <option value='2014' >2014</option>
            <option value='2015' >2015</option>
            <option value='2016' >2016</option>
            <option value='2017' >2017</option>
            <option value='2018' >2018</option>
            <option value='2019' >2019</option>
            <option value='2020' >2020</option>
            </select>
            </tr>
            <tr>
            <td>* Time (hh : mm) </td>
            <td>
            <input type="text" name="hh" id="hh" size="2" maxlength="2" value="" tabindex="5" /> : <input type="text" name="mm" id="mm" size="2" maxlength="2" value="" tabindex="6" />
            <input type="radio" name="ampm" id="ampm" value="1"  tabindex="7" /> am 
            <input type="radio" name="ampm" id="ampm" value="2"  tabindex="8" /> pm    
            </td>
        </tr>
        <tr>
        <td>* Brief Description of event / hazard :</td>
        <td><textarea name="desc" id="desc" rows="4" cols="40" tabindex="9"></textarea></td>        
        </tr>
        <tr>
            <td>If any corrective measures have been taken or required, please explain :</td>
            <td><textarea name="preventative_measures" id="preventative_measures" tabindex="10" rows="4" cols="40"></textarea></td>
        </tr>
        <tr><td>&nbsp;</td><td>&nbsp;</td></tr>
        <tr>
        <td style="font-size: small; text-decoration: underline;">2. VICTIM OR COMPLAINANT INFORMATION :</td>
        <td></td>
        </tr>        
        <tr>
            <td>* Family Name :</td> 
            <td><input name="lName" type="text" id="lName" value="" tabindex="11" maxlength="50"></td>
        </tr>
        <tr>
            <td>* First Name :</td> 
            <td><input name="fName" type="text" id="fName" value="" tabindex="12" maxlength="50"></td>
        </tr>
        <tr>
        <td>Age :</td>
        <td><input name="age" type="text" id="age" value="" tabindex="13" maxlength="2"></td>
        </tr>
        <tr>
        <td>Home telephone :</td>
        <td><input name="hTelephole" type="text" id="hTelephole" value="" tabindex="14" maxlength="20"></td>
        </tr>
        <tr>
        <td>Office telephone :</td>
        <td><input name="oTelephole" type="text" id="oTelephole" value="" tabindex="15" maxlength="20"></td>
        </tr>   
        <tr>
            <td> Email :</td>
            <td><input name="email" type="text" id="email" value="" tabindex="16"></td>
        </tr>
        <tr>
            <td>Sex :</td>
            <td>
                <input type="radio" name="sex" id="sex" value="Male"  tabindex="17" />Male
                <input type="radio" name="sex" id="sex" value="Female"  tabindex="18" />Female
            </td>
        </tr>
        <tr>
        <td>ID # :</td>
        <td><input name="idNum" type="text" id="idNum" value="" tabindex="19" maxlength="20"></td>
        </tr>
        <tr>
        <td>* Status : (At the time of event)</td>
        <td>
                <select name="status_id" id="status_id" tabindex="21">
                <option value="" ></option>
                <option value="1" >Full-time Employee</option>
                <option value="2" >Part-time Employee</option>
                <option value="3" >Contract Employee</option>
                <option value="4" >External Contractor</option>
                <option value="5" >Undergraduate Student</option>
                <option value="6" >Graduate Student</option>
                <option value="7" >Visitor</option>
                </select>
        </td>
        </tr>
        <tr>
        <td>* Department :</td>
        <td>
        <select name="dept_id" id="dept_id" tabindex="22">
        <option value=""></option>
        <option value="7">Academic Technology</option>
<option value="8">Accountancy</option>
<option value="9">Admin Negotiation Office</option>
<option value="159">Advancment and Alumni Relations</option>
<option value="10">Applied Human Sciences</option>
<option value="11">Archives</option>
<option value="12">Art Education</option>
<option value="13">Art History</option>
<option value="14">Art Supply Store</option>
<option value="166">Arts and Science</option>
<option value="15">Athletics</option>
<option value="17">Biology</option>
<option value="18">Bookstore</option>
<option value="19">Building, Civil and Environmental Engineering</option>
<option value="21">Centre for Broadcasting Studies</option>
<option value="22">Centre for Continuing Education</option>
<option value="23">Centre for Digital Arts</option>
<option value="25">Centre for Instructional Technology (CIT)</option>
<option value="28">Centre for Native Education</option>
<option value="29">Chartwells</option>
<option value="30">Chemistry and Biochemistry</option>
<option value="31">Cinema</option>
<option value="32">Classics, Modern Languages and Linguistics</option>
<option value="33">Communication Studies</option>
<option value="34">Computer Science and Software Engineering</option>
<option value="35">Computer Store</option>
<option value="37">Concordia Centre for Small Business and Entrep.</option>
<option value="40">Concordia Information Services</option>
<option value="41">Concordia Institute for Aerospace Design & Innov.</option>
<option value="42">Concordia Institute for Info Sys, Eng.</option>
<option value="43">Concordia Small Business Consulting Bureau</option>
<option value="44">Conference Services</option>
<option value="45">Contemporary Dance</option>
<option value="47">Copier Operations</option>
<option value="49">Counselling and Development</option>
<option value="52">CPE Concordia</option>
<option value="50">CPE les P'tits Profs</option>
<option value="51">Creative Arts Therapies</option>
<option value="161">Daycare</option>
<option value="53">Dean of Students</option>
<option value="54">Decision Science and Mgmt. Info. Systems</option>
<option value="55">Design Art</option>
<option value="56">Digital Image and Sound</option>
<option value="158">Distinction Cleaners</option>
<option value="57">eConcordia</option>
<option value="58">Economics</option>
<option value="60">Education</option>
<option value="1">EH&S</option>
<option value="61">Electrical and Computer Engineering</option>
<option value="62">English</option>
<option value="63">Engr & Computer Science</option>
<option value="64">Enrolment and Student Services</option>
<option value="65">Etudes francaises</option>
<option value="68">Executive Master of Business Administration</option>
<option value="66">Exercise Science</option>
<option value="69">Facilities Management</option>
<option value="70">Facilities Operations</option>
<option value="162">Facilities Operations- Carpentry/Locksmith</option>
<option value="151">Facilities Operations-Boiler room</option>
<option value="165">Facilities Operations-Custodial</option>
<option value="152">Facilities Operations-Distribution</option>
<option value="163">Facilities Operations-Electrical</option>
<option value="164">Facilities Operations-Plumbing/Mechanical</option>
<option value="71">Facilities Planning</option>
<option value="72">Finance</option>
<option value="2">Finance</option>
<option value="73">Financial Aid and Awards Office</option>
<option value="74">Financial Services</option>
<option value="75">Fine Arts</option>
<option value="76">General Studies Unit</option>
<option value="77">Geography, Planning and Environment</option>
<option value="78">Goodman Institute of Investment Management</option>
<option value="133">Graduate Studies</option>
<option value="79">Health Services</option>
<option value="80">History</option>
<option value="4">Human Resources</option>
<option value="81">Human Resources and Employee Relations</option>
<option value="86">IITS</option>
<option value="82">Institute for Canadian Jewish Studies</option>
<option value="83">Institute for Co-operative Education</option>
<option value="84">Institute in Mgmt and Community Development</option>
<option value="160">Institutional Planning Office</option>
<option value="85">Institutional Research</option>
<option value="87">Internal Audit</option>
<option value="88">Internal Relations and Communications</option>
<option value="90">International Students Office</option>
<option value="91">JMSB</option>
<option value="93">Journal of Business Research</option>
<option value="92">Journalism</option>
<option value="94">Karl Polanyi Institute of Political Economy</option>
<option value="96">Le Frigo Vert</option>
<option value="95">Learning Centre</option>
<option value="97">Leonard and Bina Ellen Art Gallery</option>
<option value="98">Liberal Arts College</option>
<option value="99">Library</option>
<option value="100">Loyola International College</option>
<option value="101">Management</option>
<option value="102">Marketing</option>
<option value="103">Marketing Communications</option>
<option value="105">Math and Statistics</option>
<option value="104">MBA</option>
<option value="106">Mechanical and Industrial Engineering</option>
<option value="107">Multi-Faith Chaplaincy</option>
<option value="108">Music</option>
<option value="6">n/a</option>
<option value="109">Native Access to Engineering</option>
<option value="111">Office of Research</option>
<option value="112">Office of Student Affairs</option>
<option value="113">Office of Student Recruitment</option>
<option value="110">Office of Student with Disabilities</option>
<option value="114">Office of the President</option>
<option value="115">Office of the Provost and Vice-President</option>
<option value="116">Office of the Registrar</option>
<option value="117">Office of the Vice-President Services</option>
<option value="118">Office of University Advancement and Alumni Rel</option>
<option value="119">Ombuds Office</option>
<option value="120">Oscar Peterson Concert Hall</option>
<option value="121">Parking and Locker Services</option>
<option value="122">Philosophy</option>
<option value="123">Physics</option>
<option value="124">Political Science</option>
<option value="125">Print and Copy Services</option>
<option value="126">Protocol and Special Events</option>
<option value="127">Psychology</option>
<option value="128">Public Affairs and Government Relations</option>
<option value="129">Purchasing Services</option>
<option value="130">Religion</option>
<option value="131">Residence Administration</option>
<option value="132">School of Community and Pulic Affairs</option>
<option value="134">Science College</option>
<option value="135">Science Technical Centre</option>
<option value="5">Security-Concordia</option>
<option value="148">Security-Corps Can. des Commiss.</option>
<option value="136">Simone de Beauvoir Institute</option>
<option value="137">Slide Library</option>
<option value="138">Sociology and Anthropology</option>
<option value="139">Student Accounts</option>
<option value="149">Students</option>
<option value="140">Studio Arts</option>
<option value="141">Support Services</option>
<option value="142">Theatre</option>
<option value="143">Theology</option>
<option value="144">Translation Services</option>
<option value="145">University Communications</option>
<option value="146">University Secretariat</option>
<option value="157">Unknown</option>
<option value="147">Visual Media Resources</option>
        </select>
        </td>
        </tr>
        <tr>
        <td>Supervisor (if applicable) :</td>
        <td><input type="text" name="supervisor" id="supervisor" value="" tabindex="23" maxlength="20"></td>
        </tr>
        <tr>
        <td>Union/Association (if applicable) :</td>
        <td>
        <select name="union" id="union" tabindex="24">
        <option value="1">-not applicable-</option>
<option value="3">ACUMAE</option>
<option value="13">CUCEPTFU</option>
<option value="11">CUFA</option>
<option value="6">CULEU-Vanier</option>
<option value="7">CULEU-Webster</option>
<option value="2">CUPEU</option>
<option value="12">CUPFA</option>
<option value="4">CUSSU</option>
<option value="8">CUUSS-TS</option>
<option value="9">SCOMM (CUSSU-TDM)</option>
<option value="10">SCOMM- Loyola Maintenance</option>
<option value="5">Unknown</option>
        </select>
        </td>
        </tr>
        <tr><td>&nbsp;</td><td>&nbsp;</td></tr>
        <tr>
        <td style="font-size: small; text-decoration: underline;">3. EVENT LOCATION :</td>
        <td></td>
        </tr> 
        <tr>
        <td>* Campus :</td>
        <td>
        <select name="camp" id="camp" tabindex="25">
        <option value=""></option>
        <option value="1">SGW</option>
<option value="2">LOY</option>
        </select>
        </td>
        </tr>
        <tr>
        <td>* Building :</td>
        <td>
        <select name="bldg" id="bldg" tabindex="26">
        <option value=""></option>
        <option value="">- LOY Campus -</option>
        <option value="6">AD</option>
<option value="7">BB</option>
<option value="8">BH</option>
<option value="10">CC</option>
<option value="87">CJ</option>
<option value="14">FC</option>
<option value="15">HA</option>
<option value="38">HB</option>
<option value="39">HC</option>
<option value="90">JR</option>
<option value="17">PA</option>
<option value="18">PB</option>
<option value="19">PE</option>
<option value="20">PG</option>
<option value="21">PS</option>
<option value="22">PT</option>
<option value="23">PY</option>
<option value="41">RF</option>
<option value="28">SC</option>
<option value="91">SI</option>
<option value="89">SP</option>
<option value="29">TA</option>
<option value="31">VE</option>
<option value="32">VL</option>
        <option value="">- SGW Campus -</option>
        <option value="45">B</option>
<option value="48">CB</option>
<option value="49">CI</option>
<option value="99">CL</option>
<option value="51">D</option>
<option value="55">EN</option>
<option value="56">ER</option>
<option value="80">EV</option>
<option value="57">FA</option>
<option value="58">FB</option>
<option value="95">FG</option>
<option value="60">GM</option>
<option value="96">GN</option>
<option value="62">H</option>
<option value="63">K</option>
<option value="64">LB</option>
<option value="66">M</option>
<option value="132">MB</option>
<option value="68">MI</option>
<option value="146">MT</option>
<option value="69">MU</option>
<option value="70">P</option>
<option value="71">PR</option>
<option value="72">Q</option>
<option value="53">R</option>
<option value="73">RR</option>
<option value="74">S</option>
<option value="86">SB</option>
<option value="75">T</option>
<option value="101">TD</option>
<option value="76">V</option>
<option value="77">VA</option>
<option value="78">X</option>
<option value="79">Z</option>
        </select>
        </td>
        </tr>
        <tr>
        <td>* Room Number :</td>
        <td><input name="roomNum" type="text" id="roomNum" value="" tabindex="27" maxlength="10" size="20"></td>
        </tr>
        <tr>
        <td>Location :</td>
        <td>
        <select name="loc" id="loc" tabindex="28">
        <option value="185"># 1</option>
<option value="191"># 2</option>
<option value="188"># 3</option>
<option value="208"># 3, in front of SP 380.01</option>
<option value="194"># 4</option>
<option value="187"># 5</option>
<option value="209"># 9</option>
<option value="1">-not applicable-</option>
<option value="182">10th floor </option>
<option value="193">11th floor # 2</option>
<option value="212">14th floor</option>
<option value="196">1st floor, Elevator  # 1</option>
<option value="218">2nd floor </option>
<option value="204">4th floor and 1st floor</option>
<option value="206">A&W Restaurant </option>
<option value="99">All Buildings</option>
<option value="197">alleyway construction container</option>
<option value="214">and the Perform Centre </option>
<option value="170">Animal Colony</option>
<option value="69">Art Gallery</option>
<option value="80">Atrium</option>
<option value="18">Auditorium</option>
<option value="221">back entrance of LB, near Tim Hortons</option>
<option value="97">Balcony</option>
<option value="166">Bank</option>
<option value="22">Bar</option>
<option value="175">basement level corridor </option>
<option value="165">Bathroom</option>
<option value="198">between RF and SP</option>
<option value="7">Boiler/Mechanical Room</option>
<option value="23">Bookstore</option>
<option value="200">Café X</option>
<option value="54">Cafeteria</option>
<option value="160">Carpentry Shop</option>
<option value="34">Chapel</option>
<option value="3">Classroom</option>
<option value="93">Commercial Establishment</option>
<option value="167">Computer Lab</option>
<option value="24">Construction Site</option>
<option value="222">Corner of Bishop and St-Catherine </option>
<option value="109">Custodial Room </option>
<option value="205">D annex </option>
<option value="173">Daycare</option>
<option value="181">Dome </option>
<option value="26">Doorway</option>
<option value="16">Eating Areas</option>
<option value="174">Electrical shop </option>
<option value="202">Elevator # 1, 5th floor</option>
<option value="201">Elevator # 3,  between 5 and 6th floor</option>
<option value="195">Elevator H1, Level RC</option>
<option value="145">Emergency Exit</option>
<option value="57">Escalator</option>
<option value="207">EV GYM</option>
<option value="217">exit LB building, Mackay side.</option>
<option value="6">Facilities Shop</option>
<option value="213">Football field </option>
<option value="190">Freight Area</option>
<option value="220">fume hood </option>
<option value="177">garage level</option>
<option value="216">GE</option>
<option value="37">Green House</option>
<option value="192">Guy Metro level</option>
<option value="8">Gym / Sports Complex</option>
<option value="10">Hallway</option>
<option value="169">Health Services</option>
<option value="199">I-R13</option>
<option value="219">in the vicinity of a lounge area</option>
<option value="211">JR, TA, BB, BH</option>
<option value="78">Kitchen</option>
<option value="4">Lab</option>
<option value="63">Laundry Room</option>
<option value="210">LB, EV, CL, TD, SB</option>
<option value="11">Library</option>
<option value="12">Loading Dock</option>
<option value="53">Lobby</option>
<option value="31">Mailroom</option>
<option value="70">Mezzanine</option>
<option value="180">North East side of building </option>
<option value="2">Office</option>
<option value="27">Other</option>
<option value="15">Outdoors off Concordia Property</option>
<option value="14">Outdoors on Concordia Property</option>
<option value="184">outside Print Shop PS 150</option>
<option value="56">Outside unsure if Concordia Property</option>
<option value="13">Parking Lot</option>
<option value="215">PC (PERFORM Centre)</option>
<option value="139">Ramp</option>
<option value="203">RC level, Elevator # 5</option>
<option value="186">recycling </option>
<option value="17">Residences</option>
<option value="19">Roof</option>
<option value="189">S, M and CI Annexes</option>
<option value="179">S1 level </option>
<option value="155">Security Desk</option>
<option value="36">Shuttle Bus</option>
<option value="183">Soccer field </option>
<option value="9">Stairs/Elevator</option>
<option value="178">stockroom</option>
<option value="67">Terrace</option>
<option value="172">theatre</option>
<option value="46">Tunnel</option>
<option value="176">woodshop</option>
<option value="5">Workshop/Studio</option>
        </select>
        </td>
        </tr>
        <tr><td>&nbsp;</td><td>&nbsp;</td></tr>
        <tr>
        <td style="font-size: small; text-decoration: underline;">3. INJURY :</td>
        <td></td>
        </tr>
        <tr>
        <td>Type of Injury :</td>
        <td>
        <select name="injury" id="injury" tabindex="29">
        <option value="1">-not applicable-</option>
<option value="7">Allergic Reaction/Asthma</option>
<option value="3">Bruise/Contusion/Swelling</option>
<option value="4">Burn</option>
<option value="25">Carpal Tunnel Syndrome</option>
<option value="23">Concussion</option>
<option value="18">Contagious/Infectious Disease</option>
<option value="26">Cut</option>
<option value="5">Fracture/Dislocation</option>
<option value="16">Headache</option>
<option value="14">Hearing Impairment/Loss</option>
<option value="22">Hernia</option>
<option value="8">Irritation/Skin Rash</option>
<option value="2">Laceration/Puncture</option>
<option value="11">Loss Consciousness/Shock</option>
<option value="21">Material Damage</option>
<option value="20">No Injury/Illness</option>
<option value="24">Pain</option>
<option value="17">Personal Illness</option>
<option value="10">Poisoning</option>
<option value="27">Splinter</option>
<option value="6">Sprain/Pulled Muscle</option>
<option value="9">Tendinitis/Repetitive Strain Injury</option>
<option value="15">Tiredness/Exhaustion</option>
<option value="13">Visual Impairment/Loss</option>
<option value="19">Work Related Stress</option>
        </select>
        </td>
        </tr>
        <tr>
        <td>Body Part Injured :</td>
        <td>
        <select name="bodyPart" id="bodyPart" tabindex="30">
        <option value="1">-not applicable-</option>
<option value="19">Ankle</option>
<option value="21">Arm</option>
<option value="14">Back/Lumbar</option>
<option value="12">Back/Muscle</option>
<option value="10">Chest/Torso/Ribs</option>
<option value="26">Digestive System</option>
<option value="6">Ear</option>
<option value="22">Elbow</option>
<option value="4">Eye</option>
<option value="3">Face</option>
<option value="20">Foot/Toes</option>
<option value="24">Hand/Fingers</option>
<option value="2">Head</option>
<option value="16">Hip/Pelvis/Groin</option>
<option value="18">Knee</option>
<option value="17">Leg</option>
<option value="8">Mouth/Teeth/Jaw</option>
<option value="11">Neck</option>
<option value="5">Nose</option>
<option value="25">Respiratory System</option>
<option value="9">Shoulder</option>
<option value="27">Stomach</option>
<option value="15">Thigh</option>
<option value="7">Throat</option>
<option value="23">Wrist</option>
        </select>
        </td>
        </tr>
        <tr>
        <td>Type of treatment :</td>
        <td>
        <select name="treatMent" id="treatMent" tabindex="31">
        <option value="1">None</option>
<option value="2">First-Aid administered, return to work</option>
<option value="3">Saw a physician, return to work</option>
<option value="4">Saw a physician, return to work, light duty</option>
<option value="5">Saw a physician, time loss</option>
<option value="6">Refused medical treatment</option>
<option value="7">not applicable</option>
<option value="8">Student-n/a</option>
<option value="9">Student-First-aid administered</option>
        </select>
        </td>
        </tr>
        <tr>
        <td>Transportation recommended :</td>
        <td>
        <select name="transRec" id="transRec" tabindex="32">
        <option value="No">No</option>
<option value="Yes - Ambulance">Yes - Ambulance</option>
<option value="Yes - Car">Yes - Car</option>
<option value="Yes - Taxi">Yes - Taxi</option>
        </select>
        </td>
        </tr>
        <tr>
        <td>* Transportation Refused :</td>
        <td>
            <input type="radio" name="transport" id="transport" value="Y"  tabindex="33" />Yes
            <input type="radio" name="transport" id="transport" value="N"  tabindex="34" />No
        </td>
        </tr>
        <tr>
        <td>If Yes, state reason :</td>
        <td><input type="text" name="refTrans" id="refTrans" value="" maxlength="50" size="50" tabindex="35" /></td>
        </tr>
        <tr>
        <td>Employees only: Consequence of Injury (check one) :</td>
        <td>
        <select name="consequence" id="consequence" tabindex="36">
        <option value="1" >Not Applicable</option>
        <option value="8" >No First-Aid administrated, return to work</option>
        <option value="2" >First-Aid administrated, return to work</option>
        <option value="3" >Saw a physician, return to work</option>
        <option value="4" >Saw a physician, time loss</option>
        </select>
        </td>
        </tr>
        <tr>
        <td>If there was time loss from work, please indicate how long (in days) :</td>
        <td><input type="text" name="timeLoss" id="timeLoss" size="5" maxlength="5" tabindex="37" value="" /></td>
        </tr>
        </tr>
        <tr><td>&nbsp;</td><td>&nbsp;</td></tr>
        </table>
        <div>
        <td style="font-size: small;">If the victim is unable to complete the Injury(Accident) / Incident / Illness / Hazard Report, the event should be reported by a witness or a supervisor.</td>
        </div>
        <table width="900" border="0" cellspacing="0" cellpadding="5" id="main2">
        <tr><td>&nbsp;</td><td>&nbsp;</td></tr>
        <tr>
        <td>Reported by :</td>
        <td><input type="text" name="reportedBy" id="reportedBy" maxlength="20" size="20" tabindex="38" value="" /></td>
        </tr>
        <tr>
        <td>Department :</td>
        <td><input type="text" name="reportedByDept" id="reportedByDept" maxlength="20" size="20" tabindex="39" value="" /></td>
        </tr>        
        <tr>
        <td>Telephone :</td>
        <td><input type="text" name="reportedByTel" id="reportedByTel" maxlength="20" size="20" tabindex="40" value="" /></td>
        </tr>
        <tr>
        <td>Email :</td>
        <td><input type="text" name="reportedByEmail" id="reportedByEmail" maxlength="20" size="20" tabindex="41" value="" /></td>
        </tr>
  </table>
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